Psychiatry Flashcards
A 79-year-old woman with a diagnosis of Alzheimer’s disease is causing concern as she is constantly getting lost on the way back from the local shop to her home, which is only a short walk and one that she has done nearly every day for 20 years. What sort of memory disturbance does this represent?
a) Autobiographical memory
b) Episodic memory
c) Procedural memory
d) Semantic memory
e) Topographical memory
E
Topographical memory loss is failure to orientate oneself.
Autobiographical memory describes specific, personal events such as birthday parties, anniversaries, and holidays. This is also known as explicit memory, or episodic memory.
Procedural memory is also known as implicit memory, such as knowing how to drive, or how to play the piano.
Semantic memory is general knowledge, such as knowing geographical capitals or historical events.
A 72-year-old woman who suffers from Alzheimer’s disease is asked who the Prime Minister was during the Second World War, to which she replies ‘Winston Churchill’. She is then asked where she lived during the war, to which she answers ‘Winston Churchill’. What phenomenon is being described here?
a) Confabulation
b) Déjà vu
c) Ganser’s syndrome
d) Jamais vu
e) Perseveration
E
Perseveration is almost solely seen in organic brain diseases, such as dementia. It isn’t limited to verbal responses, and can be a response to a motor skill.
Confabulation is the phenomenon of false memories leading to incorrect answers, which can be difficult to differentiate from delusions.
Deja but is a sense of familiarity of having encountered something before, even though it is a new event. It can be a feature of temporal love epilepsy, but is also frequently non-pathological.
Ganser’s syndrome is an unusual phenomenon in which people give approximate answers, such as “How many legs does a cow have?” “Five.” It’s also associated with other dissociative symptoms such as fugue, amnesia, and conversion disorder.
Jamais vu is the sense of never having encountered a familiar situation.
A young woman wakes from a nightmare and sees her dressing gown hanging from the door, which she mistakes as an assailant. What is being described here?
a) Affect illusion
b) Completion illusion
c) Pareidolic illusion
d) Tactile hallucination
e) Visual hallucination
A
An illusion is a misinterpretation of a perception, and are not usually pathological. An affect illusion is dependent on current emotional state, as in this scenario.
A completion illusion is when there is a lack of attention and perception is incorrectly interpreted, for example skipping over a misprint in a book.
A pareidolic illusion is a shape being seen in other objects, such as animals in the clouds, or Jesus in toast.
A hallucination is a new perception in the absence of a stimulus. The can be tactile, visual, olfactory, auditory, or taste.
A young man with schizophrenia describes how he can hear the secret service in their base in Finland discussing their plans to assassinate him. What is this phenomenon known as?
a) Extracampine hallucination
b) Functional hallucination
c) Hypnagogic hallucination
d) Hypnopompic hallucination
e) Reflex hallucination
A
Hallucinations are new perceptions in the absence of stimuli. An extracampine hallucination is one that occurs outside the usual range of sensation, in this case, beyond the limits of audibility.
A functional hallucination is experienced only when an external stimulus of the same modality occurs, for example only hearing voices when classical music is playing.
Hypnagogic and hypnopompic hallucinations are those experienced upon falling asleep and waking up respectively, such as the feeling of falling off a cliff when sleeping.
Reflex hallucinations are similar to functional hallucinations but with two different modalities, such as listening to classical music and then having a visual hallucination.
A 28-year-old man is diagnosed with schizophrenia, with the belief that he has been targeted for extermination by a religious cult who have implanted tiny electrical ‘ants’ into his fingernails. When asked when he knew this, he said he had seen a magazine story 3 months ago on ‘retiring to the country’ and immediately felt this was a covert message from the cult that he should be ‘retired’. There was no evidence of delusions prior to this. What is being described here?
a) Autochthonous (primary) delusion
b) Autoscopy
c) Delusional atmosphere
d) Delusional memory
e) Delusional perception
E
Delusional perceptions occur when a normal perception is invested with delusional meaning.
Autochthonous or primary delusions arise spontaneously with no stimulus. Secondary delusions are similar, but are understandable based on the sufferer’s mood or history.
Autoscopy is the sensation of seeing oneself (for example, out-of-body experiences).
Delusional atmosphere or delusional mood is the sensation that something is ‘going on’ without being able to state what.
Delusional memory is when a patient recalls an event and interprets it with delusional meaning.
A 48-year-old man with poorly controlled schizophrenia is admitted to the ward. He appears confused and he is difficult to interview. On asking him why he is in hospital, he replies, ‘Jealousy, the Collaborative, collaborate and dissipate. What’s in my fridge? It isn’t my time.’ How would you describe this type of thinking?
a) Circumstantial
b) Derailment
c) Flight of ideas
d) Pressure of speech
e) Thought blocking
B
Derailment is a type of formal thought disorder in which disjointed thoughts occur with no meaningful connections.
Circumstantial thinking occurs when the person talks about a subject exhaustively with only loosely relevant associations.
Flight of ideas is accelerated thinking with logical associations, but with poor attention and rapidly changing goals of thinking. Pressure of speech is the verbal description of flight of ideas.
Thought blocking is when the patient stops mid-sentence without being able to explain why. It is different to thought withdrawal, in which the patient believes an external agency is removing thoughts from their head.
Which of the following is not a first-rank symptom of schizophrenia as described by Schneider?
a) Delusional perception
b) Persecutory delusions
c) Running commentary
d) Somatic passivity
e) Thought alienation
B
Schneider’s first rank symptoms include auditory hallucinations (often repeating the subject’s thoughts out loud, referring to him/her in 3rd person, or giving a running commentary of thoughts and behaviour); thought insertion, broadcasting, and withdrawal (all by an external agency or body); passivity experiences (the idea that actions, sensations, bodily movements, emotions, or thought processes are generated by an outside agency); primary delusions; and delusional perception.
Persecutory delusions are not a first rank symptom.
The first-rank symptoms are not pathognomic of schizophrenia, and not everyone with schizophrenia experiences first-rank symptoms.
A 72-year-old man with Parkinson’s dementia is seen in clinic. He is asked how he is feeling, to which he replies, ‘I feel fantastic…tic…tic…tic…tic…’. What is the name for this type of speech abnormality?
a) Alogia
b) Dysarthria
c) Echolalia
d) Logoclonia
e) Neologism
D
Logoclonia is often seen in Parkinson’s and describes the last syllable of a word being repeated.
Alogia is extreme poverty of speech.
Dysarthria is a difficulty in manufacturing speech, usually from structural lesions in the vocal cords or brainstem.
Echolalia is repetition of words or sentences, sometimes continuously or incessantly.
Neologisms are new words created by the patient that have specific meanings, usually to do with their delusional beliefs. This is different to metonymy, which is using known words in a different way.
A 26-year-old man is seen by his GP. For the last few months, he has become increasingly concerned about a mole on his cheek, which he feels has got bigger, and people are noticing it more. Over the last week he has become convinced people are laughing at it when he passes them. He has a thought in his head of ‘you’re so ugly, look at the size of that mole’. The patient does not feel he knows where the thought comes from, but it does not seem to be his. He wonders if someone has planted the thought there. The GP does not feel the mole is in any way abnormally sized or has other unusual features. What is the most likely aetiology of these symptoms?
a) Compulsion
b) Delusion
c) Hallucination
d) Rumination
e) Somatisation
B
The intrusive thought that the thought is not his own suggests this is a delusion. A rumination would be recognised as being the patient’s own thought.
A hallucination is a perception with no stimulus.
A compulsion is a repetitive act driven by obsessive anxiety.
Somatisation is a physical symptom as a result of intrapsychic anxiety with no adequate physical explanation.
Which of the following is not a core symptom of depression as defined by ICD-10?
a) Anergia
b) Anhedonia
c) Anorexia
d) Hyperphagia
e) Insomnia
D
The three core symptoms of depression are anergia, anhedonia, and low mood.
Other symptoms according to the ICD10 include low concentration, insomnia, tiredness, low self-esteem, early morning wakening, psychomotor retardation, agitation, loss of appetite, weight loss, and loss of libido.
In atypical depression, symptoms may manifest as hypersomnia, hyperphagia, and weight gain.
A 42-year-old man sees his GP after witnessing a horrific motorway pile-up. For the last 6 weeks he has been experiencing recurrent and intrusive images of the even where he relives what happened, both at night and during the day. At night he is also having vivid nightmares about the crash which is now stopping him from going to sleep. He has not driven his car since, although he himself was not involved in the crash. Every time a car starts he jumps and becomes extremely upset. His mood is low and he feels disconnected from his wife and children and he has been thinking about killing himself. What symptom is not being described here?
A) Avoidance B) Detachment C) Insomnia D) Increased arousal E) Night terrors
E
Night terrors are not nightmares. The subject does not usually remember bad dreams, but awakes confused and terrified, sometimes lashing out, shouting, and screaming.
Avoidance symptoms, detachment, insomnia, and increased arousal (in jumping at the sounds of car engines) are present here.
A 42-year-old man sees his GP after witnessing a horrific motorway pile-up. For the last 6 weeks he has been experiencing recurrent and intrusive images of the even where he relives what happened, both at night and during the day. At night he is also having vivid nightmares about the crash which is now stopping him from going to sleep. He has not driven his car since, although he himself was not involved in the crash. Every time a car starts he jumps and becomes extremely upset. His mood is low and he feels disconnected from his wife and children and he has been thinking about killing himself. What is the most likely diagnosis?
A) Acute stress reaction B) Adjustment disorder C) Depressive episode D) Dissociative fugue E) Post-traumatic stress disorder (PTSD)
E
PTSD diagnosis includes exposure to a potentially life-threatening incident, re-experiencing the event in multiple ways (such as nightmares, flashbacks), avoidance of stimuli that recall the event, and increased arousal (including hyper vigilance, increased startle reaction, insomnia, irritability, anger). PTSD sufferers may also have depressive symptoms.
Acute stress reactions subside within hours or days of a stressful event, and cause panic, disorientation, confusion, and other symptoms of anxiety.
Adjustment disorders are a result of a significant life change (such as bereavement or emigration). They cause depression or anxiety with inability to cope with daily tasks.
Dissociative fugue is a period of amnesia during which the sufferer will travel, often for long distances before coming to, resolving usually within weeks or months. They often appear normal to passers-by.
A 49-year-old woman with schizophrenia is admitted to the psychiatric unit in a mute state. She is staring blankly ahead and not responding to any commands. She is not eating or drinking and looks dehydrated. Which of the following is least likely to be observed in catatonia?
A) Catalepsy B) Clanging C) Echolalia D) Negativism E) Stupor
B
Clanging is a thought disorder whereby words are used based on similar sounds or rhyming, with meaning becoming unimportant. For example ‘ A cat pat on my hat sack, ate the bait and skated.’ Catalonia is a state of either stupor, or excitement. It’s associated with various conditions and various symptoms.
Catalepsy is rigidity of the limbs, with movement into uncomfortable positions being retained. It is not cataplexy, in which there is a sudden transient loss of muscle tone causing collapse.
Echolalia is repetition by sufferers of words spoken to them.
Negativism is a symptom in which catatonic patients do the opposite of what is asked.
Which of the following statements regarding the two classification systems in psychiatry (ICD-10 and DSM-IV) is false? Note this refers specifically to the section in ICD-10 related to psychiatry and mental health.
A) Dementia cannot be classified in either of the two systems
B) DSM-IV uses a multiaxial system
C) Homosexuality is no longer a diagnostic category in the two systems
D) ICD-10 was developed by the World Health Organisation (WHO)
E) The first categories in ICD-10 are those related to organic disorders
A
Dementia is classified in both systems, though not all subtypes are accurately definable.
DSM-IV uses 5 axes: 1 (clinical disorders), 2 (personality disorders and learning disabilities), 3 (acute medical conditions and physical disorders), 4 (psychosocial and environmental factors contributing to the disorder), and 5 (global assessment of functioning). ICD-10 only has a single category per diagnosis.
Which of the following would be the best definition of the term ‘loosening of associations’?
A) A decrease in the amount of words produced by a patient
B) An incompleteness of the development of ideas or thoughts, leading to a lack of logical relationship between them
C) Difficulty in verbalising names of objects, despite being able to describe their function
D) Talking in a roundabout manner before finally answering a question
E) The creation of a new word with particular meaning to the patient
B
Loosening of associations is an incompleteness of the development of ideas or thoughts, leading to a lack of logical relationship between them.
Alogia is a decrease in the amount of words produced by a patient.
Nominal dysphasia is difficulty in verbalising names of objects, despite being able to describe their function, and is seen in organic disorders.
Circumstantiality is talking in a roundabout manner before finally answering a question, seen in hypomanic states.
Neologism is the creation of a new word with particular meaning to the patient, seen in schizophrenia.
A man is admitted to accident and emergency after being found semi-conscious in the street. He is unkempt and does not have any information on his person; he appears to be homeless. In accident and emergency he has a tonic clonic seizure which is self-limiting after 3 minutes. The man is post-ictal for a short time but soon becomes restless, tremulous and sweaty. His speech is rambling, and he complains about the bed sheets being filthy and ‘filled with mites’. He is tachycardic with a BP or 186/114mmHg. What is the most likely diagnosis?
A) Alcoholic hallucinosis B) Delirium tremens C) Cocaine withdrawal D) Diabetic ketoacidosis E) Opiate overdose
B
Delirium tremens is a syndrome caused by alcohol withdrawal in chronic alcohol use or dependency. It’s a medical emergency characterised by autonomic instability, nausea and vomiting, altered mental state, tremor, seizures, and hallucinations. The symptoms appear 6-12h after the last drink and peak at 24-48h.
Alcoholic hallucinosis is another symptom of alcohol withdrawal. It’s quite rare, and involves auditory hallucinations.
Cocaine withdrawal can cause formication, the physical sensation of ants crawling over one’s skin, but does no cause autonomic instability or seizures.
Diabetic ketoacidosis causes severe thirst, abdominal pain, confusion, and decreased level of consciousness.
Opiate overdose causes pinpoint pupils, and respiratory and central nervous system depression.
A man is admitted to accident and emergency after being found semi-conscious in the street. He is unkempt and does not have any information on his person; he appears to be homeless. In accident and emergency he has a tonic clonic seizure which is self-limiting after 3 minutes. The man is post-ictal for a short time but soon becomes restless, tremulous and sweaty. His speech is rambling, and he complains about the bed sheets being filthy and ‘filled with mites’. He is tachycardic with a BP or 186/114mmHg. You order a full set of bloods on this man. Which of the following results would be most indicative of the underlying cause of his delirium?
A) Elevated serum glucose B) Elevated serum potassium C) Low mean corpuscular volume (MCV) D) Low serum vitamin B12 E) Raised platelets
D
Chronic alcohol use causes B12 deficiency due to poor nutritional intake and the toxic effect of alcohol on bone marrow. B12 is used in DNA synthesis, and deficiency leads to impaired erythrocytes metabolism. This causes a raised MCV. Alcohol can also cause thrombocytopenia, hypoglycaemia, and hypocalcaemia.
A 73-year-old woman is admitted to hospital with an infective exacerbation of chronic obstructive pulmonary disease (COPD). Apart from COPD and hypertension, she has no other medical problems. On the third day of her admission, she becomes acutely confused. During the night she is awake, shouting constantly for her husband, claiming that the nurses are prison guards and that they are keeping her against her will. She is slightly calmer the day after. You are the FY1 on call and are asked to come and see her over the weekend as the nurses are worried. It will happen again at night. What should your initial management be?
A) Prescribe clozapine 25mg bd regularly
B) Prescribe haloperidol 2mg intravenously immediately
C) Prescribe lorazepam 0.5mg orally just before bedtime
D) Prescrive lorazepam 0.5mg orally twice daily regularly
E) Prescribe nothing at this stage
E
This is delirium, an acute confusional state characterised by a recognised causative factor, older age, and fluctuating confusion.
Managing delirium is conservative unless the patient is putting themself or others at risk of harm. Management may involve using a side room, reassurance, having prominent clocks and appropriate lighting for the time of day, and treating the underlying cause.
If medication is needed, low dose haloperidol is the most useful, but oral prescription would be adequate, unless refusal occurs. As medications can be a cause of delirium, and worsen it, they should only be used if absolutely necessary. BZDs are second-line agents, but again should only be uesd sparingly. Clozapine is used for treatment-resistant schizophrenia, so is not appropriate here.
Which of the following medications is most likely to be associated with an organic depressive disorder?
A) Prednisolone B) Sertraline C) Thyroxine D) Tramadol E) Tryptophan
A
Prednisolone is a corticosteroid, and may cause mania, psychosis, or depression.
Sertraline may cause a rise in suicidal ideation, however it is debated, and could be a result of side effects such as restlessness (akathisia) rather than an actual organic depressive disorder.
Thyroxine is not associated with depressive disorders.
Tramadol and other opiates are not depressive, and may in fact cause central serotonin release, with antidepressant effects. Augmentation of treatment-resistant depression treatments has been reported with opioid use.
Tryptophan is a precursor of serotonin, and may be used as an augmentation strategy in treatment-resistant depression.
A 27-year-old man is involved in a road traffic accident. During rehabilitation, his family have become very upset as they feel that he has ‘changed’. They report that his concentration is poor and at times he is saying very hurtful things to his wife, which they say is extremely out of character. He has also begun eating large quantities of junk food, whereas before he was extremely fit and careful with his diet. Which part of the brain is most likely to have suffered an injury?
A) Basal ganglia B) Frontal lobe C) Limbic structures D) Parietal lobe E) Occipital lobe
B
Frontal lobe syndromes tend to cause personality changes including an inappropriate or fatuous affect, lability of mood, hypersexuality, hyperphagia, and childishness. There is no insight into the change, and poor concentration may also occur. Forced utilisation is another phenomonen observed, in which patients must use objects in front of them. Primitive reflexes may also be present.
Basal ganglia injuries cause slowing of movement and lack of spontaneity, and increase in obsessional symptoms. Contusions are uncommon, but cerebral hypoxia can injure them.
Limbic injury would result in some kind of amnesic syndrome.
Partietal lobe lesions are associated with visuo-spatial deficits such as agnosias or dyspraxias. Dysphasias may also occur.
Occipital lobe lesions can cause complex visual disturbances, including Anton’s syndrome, in which the patient is cortically blind with no insight, continuing to affirm adamantly that they can see.
A 28-year-old woman is admitted to hospital systemically very unwell, with a reduced level of consciousness, headache, fever, nausea and vomiting, and dysphasia. This is followed by several seizures. initial cerebrospinal fluid analysis shows the CSF is clear, with raised protein, raised mononuclear cell count, no polymorphs, and normal glucose. Her partner says that for the preceding few days she had been acting strangely, seeing things that were not there, accusing him of leaving the gas on and getting very agitated. She then became drowsy and he called the ambulance. Your initial management should be based on which being the most likely diagnosis?
A) Bacterial meningitis B) Herpes simplex encephalitis C) Neurosyphilis D) Sporadic Creutzfeld-Jakob disease (CJD) E) Temporal lobe epilepsy
B
HSV encephalitis tends to target the temporal and orbitofrontal structures, causing unusual behaviour or psychotic symptoms, including olfactory hallucinations (as with the gas in this case). HSV encephalitis has a 70% mortality rate, and IV aciclovir is needed as soon as possible. The CSF is in keeping with viral encephalitis.
Bacterial meningitis would give a turbid or purulent CSF, with high polymorphs, high protein, and low glucose.
Neurosyphilis would be uncommon in a woman of this age, though not impossible.
Sporadic CJD presents with rapid onset dementia with associated mood symptoms, spasticity, and blindness.
Temporal lobe epilepsy seizures are gradual in onset characterised by motionless stares and automatisms. Auras are common and may mimic typical psychotic hallucinations of any modality.
A 76-year-old man with squamous cell lung carcinoma attends accident and emergency with his wife who is his full-time carer. She has become concerned as he has become extremely depressed over the last couple of weeks, along with being extremely thirsty and having little energy. Up until then he was coping very well with his diagnosis. What is the most likely cause of these symptoms?
A) Hypercalcaemia B) Hypocalcaemia C) Hyperkalaemia D) Hypokalaemia E) Hypophosphataemia
A
Hypercalcaemia is a common side effect of cancers. In squamous cell lung carcinoma, it is likely a result of parathyroid-related peptide release causing increased bone turnover, or direct bone invasion. Hypercalcaemia causes kidney stones, bone pain, constipation, depression and confusion. Thirst, nausea, vomiting, and anorexia are also common.
Hypocalcaemia causes peripheral neurological signs, such as hyperreflexia, tetany, paraesthesia, and bruising. Psychiatric symptoms may occur, but with no particular pattern.
Hyperkalaemia causes muscle weakness and fatigue.
Hypokalaemia may cause muscle weakness, fatigue, depression, and anxiety.
Hypophosphataemia usually causes a delirium, with motor problems.
A 14-year-old boy, with no prior psychiatric or medical history, is noted to be seriously slipping in his GCSE coursework, after previously being a Grade A student. He has also started behaving recklessly, going out late whereas previously he had been shy with few friends. He is getting into frequent fights at school. Other changes include the onset of tremor and strange writhing movements in his arms. His mother has also noticed that his skin appears to have taken on a yellow tinge. What is the most likely diagnosis?
A) Huntington's disease B) Multiple sclerosis C) Multiple system atrophy D) Wilson's disease E) Young-onset Parkinson's disease
D
Wilson’s disease is an autosomal recessive disorder of copper metabolism. This causes copper accumulation in numerous tissues, including the liver and CNS. Kayser-Fleischer rings are also observed. Symptoms include liver failure, aggression, reckless behaviour, disinhibition, and sometimes self-harm.
Huntington’s disease is an autosomal dominant movement disorder. It causes accumulation of inclusion bodies leading to cell death in the basal ganglia, substantia nigra, and cerebellum. This results in choreoid and athetoid movements, dementia, and perosnality changes. It usually presents in the 4th and 5th decades of life.
MS is an inflammatory demyelinating disease. It can be episodic or progressive, and is characterised by a wide range of neurological, psychiatric, and cognitive symptoms.
Multiple system atrophy is a are disease of unknown cause, clinicaly similar to Parkinson’s disease, but with more involvement of the putament and caudate nuclei, and no Lewy bodies in the substantia nigra. Dementia does no occur, but sleep disorders and depression is common.
Juvenile PD is rare and similar to PD, but with more dystonia. Depression may occur, and dementia is almost unheard of in younger patients.
Which of the following is the most common psychiatric manifestation following stroke?
A) Anxiety symptoms B) Delusions C) Depressive symptoms D) Hallucinations E) Obsessive-compulsive (OCD) symptoms
C
Prevalence of depression in stroke is around 1 in 3, higher than expected from chronic disease alone, suggesting some organic cause.
Psychotic symptoms may occur in 1-2% of stroke patients. Antipsychotics in patients with co-morbid dementia can increase risk of death, so care should be taken.
Anxiety symptoms are seen in up to 1 in 4 stroke patients.
OCD is rare in stroke.
A 38-year-old man is admitted with a several week history or rapidly deteriorating memory, which he covered to some extent with extensive confabulation. He was also found to be sleeping, drinking, and eating excessively. On examination he was pyrexial. His blood work showed a markedly raised serum osmolality. An MRI shows an intracranial mass. Where is the most likely anatomical location for this lesion? A) Around the third ventricle B) Cerebellum C) Corpus callosum D) Frontal lobe E) Pons
A
The thalamus and hypothalamus are at the base of the third ventricle, leading to the symptoms described. The raised serum osmolality is a result of cranial diabetes insipidus.
Cerebellar tumours would be less psychiatric, but raised ICP may cause dementia-like symptoms. Symptoms would include signs such as ataxia, and nystagmus.
Corpus callosum tumours produce profound psychiatric problems, and rapid deterioration of higher functions, including catatonia and severe memory problems.
Frontal lobe tumours cause personality change and may be mistaken for dementia.
Pons tumours tend to be aggressive gliomas, presenting with nausea, headache, vomiting, diplopia, drowsiness, and dysarthria.
A 34-year-old woman presents to accident and emergency claiming that the devil has returned to earth and is hunting her through her neighbours, who are recording her every movement. The psychiatric assessment shows florid delusions and auditory hallucinations. She has no past psychiatric history. Her husband tells you that she was fine up until 2 weeks ago. Her hands have also been shaking and she has complained that the devil has been torturing her muscles. She has widespread lymphadenopathy and an enlarged spleen. An unusual rash is present across her cheeks and nose, which she says is the brand of the devil. What is the most likely diagnosis?
A) Behcet's disease B) CREST syndrome C) Graves' disease D) Systemic lupus erythematosus (SLE) E) Wegener's granulomatosis
D
SLE is an autoimmune connective tissue disorder that can affect any organ in the body. It presents most commonly in women of the 3rd or 4th decade. Neuropsychiatric symptoms such as psychosis, dementia-like illnesses, or affective disorders may present at the beginning of the disease course. Parkinsonism, myalgia, lymphadenopathy, splenomegaly, and the malar rash suggest a functional psychiatric disorder is unlikely, and SLE would explain all of her symptoms.
Behcet’s disease is an autoimmune disorder causing recurrent mouth ulcers, genital ulcers, and uveitis.
The CREST syndrome is a type of scleroderma. It is characterised by Calcinosis, Raynaud’s phenomonen, oEsophageal atresia, Sclerodactyly, and Telangiectasia.
Graves’ disease is an autoimmune thyroiditis, which can occur with SLE, or, more commonly, rheumatoid arthritis. Hyperthyroid signs are seen.
Wegener’s granulomatosis is an autoimmune vasculitis that affects the lungs, kidneys, and nervous system. It presents with dyspnoea, cough, haemoptysis, nasal ulceration, sinusitis, systemic symptoms, haematuria, and peripheral neuropathy.
Which of the following vitamin deficiencies is most likely to lead to a triad of gastrointestinal disturbance, dermatological symptoms, and a heterogeneous constellation of psychiatric symptoms?
A) Niacin B) Vitamin A C) Vitamin B1 D) Vitamin C E) Vitamin D
A
Niacin is also known as nicotinic acid. The deficiency is known as pellagra. It causes diarrhoea, anorexia, gastritis, symmetrical bilateral bullous lesions in sun-exposed areas, apathy, depression, and irritability. Later stages can develop to delirum, psychosis, or a Korsakoff-like presentation. Treatment with nicotinic acid leads to prompt and dramatic improvements.
Vitamin A deficiency is associated with night blindness, dry skin, and anaemia.
Vitamin B1 (thiamine) is known as beriberi. It causes neuropathy and heart failure. Acute depletion, as in Wernicke’s, leads to encephalopathy.
Vitamin C deficiency causes scurvy, which involves anorexia, diarrhoea, irritability, anaemia, gingival haemorrhage, poor wound healing, leg pain, and swelling over the long bones.
Vitamin D deficiency causes rickets in children and osteomalacia in adults. It may have a role in seasonal affective disorder.
Which of the following statements regarding neuropsychiatric manifestations of epilepsy is correct?
A) Automatisms in epilepsy are usually pre-ictal
B) Epilepsy is usually associated with enduring personality difficulties
C) Psychosis is negatively correlated with epilepsy
D) Rates of suicide are higher in people with epilepsy than people not suffering with epilepsy
E) Temporal lobe epilepsy is uaully associated with tonic clonic seizures
D
Epilepsy has many neuropsychiatric and psychological interactions. As well as rates of suicide, co-morbid psychiatric illnesses are higher than in the general population.
Auomatisms are repetitive motor activities observed in most forms of epilepsy, but most often in complex partial seizures (such as temporal lobe epilepsy). They are ictal or post-ictal.
Psychotic symptoms are positively correlated with epilepsy, particularly temporal lobe epilepsy.
Temporal lobe epilepsy is associated with psychological and psychiatric symptoms such as aura, sensory disturbances, depersonalisation, derealisation, deja vu, and jamais vu.
Which of the following regarding early-onset dementia (or young-onset dementia (YOD)) is correct?
A) Alzheimer’s disease in younger patients is not associated with a family history
B) Alzheimer’s disease is an uncommon cause of YOD
C) Dementia is under-represented in Down’s syndrome
D) Pick’s disease is classically associated with personality change
E) YOD is usually caused by prion diseases
D
Pick’s disease is a frontotemporal dementia, presenting in the 6th decade of life. It causes changes in behaviour and personality before amnesia is obvious.
Alzheimer’s disease in younger people is associated with inherited genetic mutations, and is the major cause of YOD.
Trisomy 21 confers a much greater risk of dementia, estimated at around 50% of those aged 60 or above.
Prion diseases are very rare, and do cause YOD, but only account for about 1.5%
A 19-year-old white woman presents to accident and emergency with abdominal pain, arm weakness and diminished reflexes. She is also extremely agitated and is responding to auditory hallucinations. You are unable to get a history from her, and you call her GP - there is little of note in her history, although she has only been in the practice for a few months as she is a first year student. The only recent entry is a new prescription for the oral contraceptive pill. What is the most likely diagnosis?
A) Acromegaly B) Acute intermittent porphyria C) Diabetic ketoacidosos D) Heroin intoxication E) Sickle cell anaemia
B
Acute intermittent porphyria is is a rare autosomal dominant inherited disorder, presenting from the 2nd to 4th decade. It is a haem metabolism disorder causing porpyrins to build up. Attacks are precipitated by menstruation, alcohol, poor nutrition, and certain drugs, including the OCP. It causes abdominal pain and neuropsychiatric symptoms.
Acromegaly is increased growth hormone secretion. It has no psychiatric associations.
DKA could present with abdominal pain, but peripheral neuropathy would be unlikely at this age. Psychosis would also be uncommon, although confusion and low consciousness is common.
Heroin intoxication wouldn’t present this way. Withdrawal would cause abdominal cramps and muscle aches, but without frank weakness and changes in reflexes.
Sickle cell anaemia could cause an abdominal crisis, but is unlikely to present this late in age, in a white individual.
A 24-year-old student presents with a 3-month history of social withdrawal and low mood. She is difficult to interview because she talks about random themes and has difficulty answering questions. She has vague paranoid ideation. She is childish and pulls faces at you during the interview. The most likely diagnosis is:
A) Hebephrenic schizophrenia B) Catatonic schizophrenia C) Paranoid schizophrenia D) Residual schizophrenia E) Simple schizophrenia
A
Schizophrenia is a term that describes multiple disorders. Current classification divides schizophrenia into five subtypes.
Hebephrenic (or disorganised) schizophrenia is predominated by thought disorder and affective symptoms (often childlike and fatuous). Social withdrawal and negative symptoms are common. Psychosis is present, but fragmented and not the most striking feature.
Catatonic schizophrenia is characterised by catatonia, including psychomotor retardation and stupor, or florid over-activity. Unusual symptoms such as automatic obedience or negativism may occur. Waxy flexibility will be seen in the most severe cases. Psychosis, again, is present but is not dominating.
Paranoid schizophrenia is dominated by psychosis, and is thought of the ‘classical’ subtype.
Residual schizophrenia is late-stage schizophrenia in which positive symptoms are replaced by negative symptoms.
Simple schizophrenia is ‘the insidious development of oddities of conduct, inability to meet the demands of society, and decline in total performance’ (ICD-10). There are no overt psychotic symptoms.
What is the lifetime prevalence of schizophrenia in the UK?
A) 0.01 per cent B) 0.1 per cent C) 0.4 per cent D) 4 per cent E) 10 per cent
C
A 19-year-old twin is diagnosed with schizophrenia. His mother makes an appointment to see you at the GP practice and asks what the likelihood is of his twin developing schizophrenia. What should you tell her?
A) It is inevitable that schizophrenia will develop in the brother
B) There is no increased risk of developing schizophrenia
C) The risk is about one in 100
D) The risk is about one in 10
E) The risk is about one in two
E
The risk of 1 in 100 is vaguely that of the general population (0.4%), and 1 in 10 is the risk of developing schizophrenia if you have one first degree relative with the disease.
A 19-year-old man with schizophrenia is brought to accident and emergency by his sister as he has become unwell over the last few days. He has recently been started on risperidone. He is confused, sweaty, and tremulous. On examination, the signs include tachycardia, low BP, pyrexia, and lead-pipe rigidity. His GCS is decreased, at 12/15. What is the most likely diagnosis?
A) Acute dystopia B) Malignant hyperthermia C) Neuroleptic malignant syndrome D) Serotonin syndrome E) Tyramine reaction
C
NMS is a medical and psychiatric emergency. Without treatment, mortality is up to 30%. It’s a complication of antipsychotic use. It’s thought to be a result of dopamine blockade in the hypothalamus and nigrostriatal pathway, causing pyrexia and extrapyramidal symptoms. Peripheral blockade can exacerbate stiffness and lead to muscle breakdown, rhabdomyolysis and renal failure. Treatment is removal of the offending antipsychotic, and supportive treatment.
Acute dystonias are acute muscular spasms, side effects of antipsychotic use.
A 23-year-old man is diagnosed with schizophrenia. He has had florid persecutory beliefs and auditory hallucinations for the past 3 months. In terms of medical history he has poorly controlled insulin-dependent diabetes and is obese. On admission to hospital, he was so distressed that he required intramuscular rapid tranquilization. On administration of 5mg of haloperidol, he developed acute dystonia in his neck muscles which was excruciatingly painful. What would be the most appropriate drug to commence to control his schizophrenia?
A) Aripiprazole B) Clozapine C) Olanzapine D) Oral haloperidol E) Sertraline
A
Aripiprazole is a newer antipsychotic and has fewer side effects (less propensity to weight gain, and lower incidence of extrapyramidal side effects). It can cause nausea and insomnia, however.
Clozapine is reserved for treatment-resistant schizophrenia, usually after at least one, or usually two, other antipsychotics have been trialled.
Olanzapine is effective for positive symptoms, but usually causes weight gain and can worsen diabetic control.
Extrapyramidal side effects are caused by oral and IM formulations, so oral haloperidol would not avoid the acute dystonia.
Sertraline is an SSRI, used in depression, and not as an antipsychotic.
A 24-year-old man with a diagnosis of schizophrenia, last admitted 6 months ago under Section, is brought in by police to the Mental Health Unit under Section 136. He has been harassing his ex-girlfriend with constant threatening phone calls and turning up at her house. He says he believes she is twisting his bones at night, preventing him sleeping and causing him massive pain, through witchcraft. He states that he is going to kill her if it goes on one more night, and he has purchased a special knife from a ‘witchcraft’ shop on the internet. He is experiencing auditory hallucinations directing him in the best way to use the knife against her. Against the advice of his consultant, he has recently stopped his medication, which usually keeps him well. His symptoms typically follow these themes of violence and the supernatural when unwell. He claims that being in hospital will just allow her to target him more easily, and will not stay voluntarily. What Section of the Mental Health Act is most likely to be appropriate in this case?
A) Section 135 B) Section 2 C) Section 3 D) Section 4 E) Section 5(2)
C
Section 3 is used to detain people for up to 6 months for treatment (not diagnosis).
Section 2 is used to detain for a maximum of 28 days for assessment and treatment, used when the nature or degree of a patient’s condition is unclear.
Section 135 is a warrant allowing police to search premises and remove patients from those premises. It’s made by the AMHP to a magistrate. The police in question must be accompanied by an AMHP and a doctor.
Section 4 is an emergency Section used in exceptional circumstances for emergency admission. It requires one AMHP and only one doctor, so is used when two doctors cannot be found for a section 2 or 3.
Section 5(2) is a 72-hour section for inpatients by any fully registered medical practitioner to allow a full MHA assessment to be carried out. Section 5(4) is the equivalent for nurses, but only allows detention for 6 hours.
Section 136 is used if police believe a person has a mental illness and requires care or control. They can take the patient to a place of safety.
A 24-year-old man with a diagnosis of schizophrenia, last admitted 6 months ago under Section, is brought in by police to the Mental Health Unit under Section 136. Against the advice of his consultant, he has recently stopped his medication, which usually keeps him well. His symptoms typically follow these themes of violence and the supernatural when unwell. He is admitted under Section 3. On admission to the ward, he is acutely disturbed and becomes violent towards others and himself. He has slapped a member of staff. Staff try to calm him down but it is felt that the risks are escalating. He was prescribed 2mg lorazepam orally which he has spat into the nurse’s face. He has no prior recorded adverse drug reactions. What is the most appropriate pharmacological management of the patient?
A) Haloperidol decanoate (depot) 50mg intramuscular
B) Haloperidol 10mg orally
C) Lorazepam 2mg intramuscular
D) Lorazepam 2mg slow intravenous injection
E) Propofol 120mg intravenous injection
C
Rapid tranquilisation is used when senior advice says that non-pharmacological methods have failed and risks to the patient or others are sufficiently high.
IM lorazepam is commonly used for rapid tranquilisation. It’s often combined with IM haloperidol (non-depot). These patients should be monitored by nursing and medical staff to ensure no respiratory depression or other side effects occur. It should not be given without ensuring a supply of flumazenil (a BZD antagonist).
Haloperidol decanoate is a depot medication and would not have an immediate effect.
Lorazepam can be given as a slow IV injection but is more likely to cause respiratory depression when given this way.
Propofol is used to induce anaesthesia, not to tranquilise.
A 22-year-old man with paranoid schizophrenia has been treated with three different antipsychotics and remains unwell. His team decide to prescribe clozapine which he has now been on for 3 weeks. He comes in for his regular blood test and the nurse in the clozapine clinic asks the junior doctor to see him as he appears unwell. On examination, he is sweaty and tachycardic with a temperature of 38.5 degrees Celsius. He has no chest pain but is coughing purulent sputum. What would the most likely isolated abnormality be on blood testing?
A) High eosinophil count B) High platelet count C) Low haemoglobin D) Low lymphocyte count E) Low neutrophil count
E
Clozapine can cause neutropenia, and even agranulocytosis.
These symptoms could also be neuroleptic malignant syndrome, but that usually causes raised leukocytes, which is not an option here.
Eosinophilia is a described side effect of clozapine, but is likely to be related to side effects of myocarditis and colitis, not those mentioned here.
Similarly, thrombocytopenia and anaemia have been described with clozapine, but neither would cause this clinical picture.
Low lymphocyte count may be part of an overall decrease in all white blood cells, but wouldn’t be found as an isolated abnormality.
A 54-year-old man with schizophrenia has been on depot antipsychotics for the last 27 years as he hates taking tablets and has stopped them in the past. He has not been unwell in terms of his schizophrenia for the last decade. His community psychiatric nurse notices that he has developed odd movements around his mouth over the last few months, where he purses and smacks his lips. It is causing him difficulty speaking and is distressing for him and his family. Which is the most appropriate course of action for managing this symptom?
A) Gradual decrease in depot medication
B) Offer emotional support
C) Start anticholinergic such as procyclidine
D) Start ‘second-generation’ antipsychotic such as olanzapine
E) Stop depot immediately to prevent further deterioration
A
This symptom is tardive dyskinesia (TD), which is a side effect of long term antipsychotics. As the patient has been well for so long, a gradual decrease in medication could be tried with extreme caution and regular medical supervision. 50% of cases improve after this course of action. There may be a paradoxical increase in TD initially.
Anticholinergics can exacerbate TD.
Olanzapine and other second-generation antipsychotics tends to cause TD less than others, but as this patient is against oral medication, this wouldn’t work.
Antipsychotics should not be discontinued abruptly, unless an emergency such as neuroleptic malignant syndrome occurs.
A 22-year-old single man is diagnosed with schizophrenia. This is followed by a very rapid psychotic breakdown characterised by well-defined persecutory delusions. There is no mood component to his symptoms. He has shown a poor response to treatment. Which of the following indicates a positive prognostic feature of this man’s illness?
A) Absence of mood symptoms B) Being male C) Being young D) Poor initial response to treatment E) Rapid onset of symptoms
E
Rapid onset confers a positive prognosis in schizophrenia. All other options are associated with poorer prognosis. As well as those mentioned, poor prognostic markers include lack of social networks, being single, poor pre-morbid educational attainment, having predominantly negative symptoms, and having a long duration of illness before treatment.
A 38-year-old single woman is arrested outside the house of a celebrity TV chef after shouting outside all night. On interview, she claims that the man has declared his love for her several times, but is being prevented from seeing her by his wife, who is keeping him handcuffed inside. She states it is he that has made several advances to her by sending her special messages when he is cooking on television. What syndrome or symptom is being described here?
A) Capgras syndrome B) de Clerambault’s syndrome C) Folie a deux D) Othello syndrome E) Querulant delusions
B
de Clerambault’s syndrome is also known as erotomania. It involves the sufferer becoming delusionally convinced that someone famous has become infatuated with them. It is more common in women.
Capgras syndrome is when the sufferer believes a person close to them has been replace by a double.
Folie a deux is a rare phenomenon where two people in a close relationship develop the same delusional beliefs.
Othello syndrome is a disease of delusional jealousy, more common in men. There is potential for violence.
Querulant delusions lead to sufferers having sustained and excessive complaints and litigations against authorities, ending up in lengthy and tangled legal battles.
A 27-year-old man has been started on haloperidol, a ‘first-generation’ antipsychotic, for control of his symptoms of schizophrenia. A few weeks later, he comes to his GP in a highly embarrassed state, claiming that the CIA are experimenting on him, turning him into a woman. When the GP asks how he knows this, the man states that he has noticed his chest growing into ‘breasts’ and he can no longer get an erection with his girlfriend. What is the most likely cause of these symptoms?
A) Alpha-blockade B) Drug-induced hepatitis C) Hyperprolactinaemia D) New-onset diabetes E) Prostatic hypertrophy
C
Hyperprolactinaemia is a common side effect of antipsychotics, including second-generation. Dopamine blockade of the tuberoinfundibulnar pathway causes prolactin secretion, leading to gynaecomastia, and sexual dysfunction.
Alpha-blockade would cause sexual dysfunction but not gynaecomastia.
Drug-induced hepatitis is rare with haloperidol, and would rarely present with these symptoms.
Diabetes is unlikely to cause these symptoms in the early stages, however chronic poor control could lead to kidney failure and therefore gynaecomastia.
Prostatic hypertrophy is rare in such young men, although it can be worsened by some antipsychotics.
Which of the following is not recognised as a diagnostic feature of schizophrenia according to ICD-10?
A) Formal thought disorder B) Grandiose delusions C) Running commentary D) Symptoms lasting at least 1 month E) Thought broadcasting
B
Grandiose delusions are more commonly associated with mania.
The ICD-10 requires over one month of symptoms including ‘thought echo; thought insertion or withdrawal; thought broadcasting; delusional perception and delusions of control; influence or passivity; hallucinatory voices commenting or discussing the patient in the third person; thought disorders and negative symptoms.’
A 28-year-old woman presents in the GP surgery. She is over-talkative and over-familiar with you. It is difficult to get a full history, but it seems for the last 4 weeks she has been elated and experiencing voices telling her that her mother was a descendent of the Virgin Mary and that she is a female ‘second-coming’. This was the result of an experiment by the Nazi party who genetically engineered her grandparents. She believes that the remnants of the Nazi party are now controlling her arms and legs, which results in her alternately trying to hug you and then kicking out at the desk. What is the most likely diagnosis?
A) Hebephrenic schizophrenia B) Induced delusional disorder C) Paranoid schizophrenia D) Schizoaffective disorder E) Schizotypal disorder
D
This appears to be schizoaffective disorder of the manic type. Here, schizophrenic symptoms (delusions of passivity, auditory hallucinations) with affective disorder (manic symptoms) presenting within the same episode lead to this diagnosis.
Hebephrenic schizophrenia is a childish affect with fleeting delusions or hallucinations.
Induced delusional disorder is another term for folie a deux.
Paranoid schizophrenia would be a possible diagnosis, but delusions would be expected to be more paranoid in nature, without such florid affective symptoms.
Schizotypal disorder is a personality disorder characterised by eccentric behaviours and beliefs mimicking schizophrenia without any definite psychotic symptoms.
Which of the following is the least likely to be a side effect of antipsychotic treatment?
A) Akathisia B) Convulsions C) Hypotension D) Renal failure E) Tachycardia
D
Antipsychotics cannot cause renal failure except for in cases of neuroleptic malignant syndrome leading to rhabdomyolysis.
Akathisia or restlessness is common as an extrapyramidal side effect.
Antipsychotics can lower the seizure threshold, especially clozapine.
Hypotension is possible in adrenergic blockade, so medications are titrated to prevent sudden hypotension and collapse.
Tachycardia is a side effect of antipsychotics.
A 35-year-old woman complains of low mood after the death of her husband in a car-accident. She does not speak and remains immobile for long periods. What is the most likely diagnosis?
A) Seasonal affective disorder B) Dysthymia C) Atypical depression D) Depressive stupor E) Post-partum depression
D
Depressive stupor is characterised by mutism and akinesia. Severe psychomotor retardation can lead to dehydration and pressure sores.
SAD is depressive symptoms that recur in winter months.
Dysthymia is chronic low grade mood symptoms not amounting to a depressive illness.
Atypical depression is a depressive episode with weight gain, increased appetite, and hypersomnia.
A 45-year-old female has had persistent mild depressive features since her late teens. She sometimes experience loss of energy and tearfulness. She believes her low mood began after she was abused by her step-father as a teenager. She has no other symptoms. What is the most likely diagnosis?
A) Depressive episode B) Recurrent depressive disorder C) Dysthymia D) Cyclothymia E) Bipolar affective disorder
C
Dysthmia is chronic low grade mood symptoms not amounting to a depressive illness.
Depressive episodes are classified as one core symptom (low mood, anhedonia, and anergia) for a minimum of two weeks.
Recurrent depressive disorder is associated with repeated episodes of depression with euthymic intervals.
Cyclothymia is a persistent instability of mood with a cycle of low grade elevated and depressed mood.
Bipolar disorder is characterised by discrete episodes of mania or hypomania which may or may not be accompanied by episodes of depression.
What is the most likely condition causing a depressive episode in a 76-year-old man with a history of smoking and hypertension?
A) Multiple sclerosis B) Parkinson's disease C) Huntington's disease D) Stroke E) Spinal cord injury
D
30% of stroke patients develop depression, and this patient has a history of risk factors.
MS is sometimes associated with depression or elevation of mood.
PD is associated with depression, as is Huntington’s disease, and spinal cord injury.
A 35-year-old female visits her GP complaining of low mood and weight loss. On questioning she also experiences fatigue which is exacerbated by pain in her legs. Blood tests reveal high potassium. Which of the following is most likely to cause her depression?
A) Cushing's disease B) Addison's disease C) Hypothyroidism D) Primary hyperparathyroidism E) Premenstrual tension syndrome
B
Adrenocortical insufficiency causes fatigue, myalgia, joint pain, skin tanning, hyponatraemia, hyperkalaemia, and depression.
Cushing’s disease is high cortisol leading to irritability, aggression, and depression.
Hypothyroidism can cause depressive symptoms.
Primary hyperparathyroidism causes decreased PTH and increased calcium (moans, bones, groans, and stones).
Premenstrual tension syndrome is characterised by low mood, irritability, and stress, associated with the menstrual cycle.
A 43-year-old female visits her GP complaining of a 4-week history of fever, fatigue, low mood, and lower back pain. She had visited China in the previous month and mentioned she was drinking plenty of goat’s milk as this was the only type of milk available. What is the most likely infective cause?
A) Hepatitis C B) Infectious mononucleosis C) Herpes simplex D) Brucellosis E) Syphilis
D
Brucellosis is a contagious zoonosis transmitted via unpasteurised goat’s milk or contact with infected animals. It causes fever, headaches, fatigue, pain, and depression.
Hepatitis C is a blood borne virus, causing fever, appetite loss, and nausea. It can cause depression.
Infectious mononucleosis is caused by EBV with fever, sore throat, fatigue, and depression.
HSV can sometimes cause depressive symptoms.
Syphilis is a STD that may lead to neurological involvement, associated with psychosis, dementia, mania, and depression.
A 35-year-old woman has had a low mood for 2 months associated with fever, fatigue, and joint pain. She has a rash on her face which gets worse with exposure to the sun. What is the most likely cause of her low mood?
A) Pancreatic cancer B) Systemic lupus erythematosus (SLE) C) Rheumatoid arthritis D) Porphyria E) Pellagra
B
SLE is a multiorgan autoimmune disease associated with anti-nuclear antibodies. It can cause headaches, depression, and seizures.
Pancreatic cancer and RA are associated with depression.
Porphyrias are associated with anxiety, hallucinations, and depression.
Pellagra is caused by vitamin B3 deficiency with sensitivity to sunlight, dementia, and diarrhoea.
Which of the following is most likely to cause depression?
A) Methyldopa B) Atenolol C) Ibuprofen D) Prednisolone E) Amlodipine
D
Corticosteroids are associated with mania and depression.
Methyldopa’s side effects include depression, suicidal ideation, and nightmares.
Propranolol may cause depression as it can cross the blood-brain barrier, but atenolol cannot.
Ibuprofen is rarely associated with depression.
Amlodipine has an occasional side effect of depression, as with all calcium channel blockers.
A 25-year-old woman visits her GP complaining of low mood, fatigue, and weight gain. She is observed to be wearing several layers despite its being a warm day. On examination, she is found to have a pulse rate of 55. What is the most likely underlying diagnosis?
A) Cushing's disease B) Hypocalcaemia C) Addison's disease D) Hypothyroidism E) Diabetes mellitus
D
Hypothyroidism is associated with fatigue, weight gain, cold intolerance, and depression. Bradycardia and slow-relaxing reflexes may occur.
Cushing’s disease, Addison’s disease, and diabetes mellitus are associated with depression, but not the rest of the clinical picture.
Hypocalcaemia is rarely associated with depression.
A 45-year-old woman is taken to see a GP by her husband. He mentions that his wife has been irritable for the last two weeks. She is not sleeping well and on examination she has pressure of speech and mild elation. She is not hallucinating and there is no evidence of delusional thinking. What is the most likely diagnosis?
A) Hypomania B) Mania C) Cyclothymia D) Agitated depression E) Bipolar affective disorder
A
Hypomania is elevated mood or irritability, interfering with activities of daily living without being severely disruptive or associated with psychological symptoms.
Mania is significantly elevated mood affecting work and social activities, lasting over a week, often with mood-congruent psychotic features.
Cyclothymia is persistent instability of mood.
Agitated depression presents with irritability and anxiety, but not elation.
Bipolar affective disorder is diagnosed if two or more affective episodes have occurred, one of which must be mania or hypomania.
A 25-year-old man with bipolar disorder is seen on the psychiatric ward by a medical student. Taking a history is not easy, as the patient continually wants to speak. The patient is difficult to interrupt. What feature of mania is demonstrated by this patient?
A) Elevated mood B) Poor concentration C) Flight of ideas D) Pressure of speech E) Impaired judgement
D
Pressure of speech is a result of pressure of thought.
Elevated mood may be overly cheerful or irritable.
Flight of ideas is a patient’s thoughts moving from topic to topic, although there is usually a connection between the ideas.
A 25-year-old man is seen in accident and emergency with an elevated mood and mild signs of meningism. He has a low grade fever and a bullseye rash is seen on his left lower arm. What is the most likely diagnosis?
A) HIV B) Lyme disease C) Encephalitis D) Neurosyphilis E) Meningococcal septicaemia
B
Lyme disease is a bacterial disease transmitted by ticks causing fever, headache, fatigue, and mood changes. An expanding bullseye rash known as erythema chronic migraines occurs.
HIV can cause manic symptoms.
Encephalitis can cause confusion, headaches, cognitive decline, and mania.
Syphilis is a STD that may lead to neurological involvement, associated with psychosis, dementia, mania, and depression.
Meningococcal septicaemia presents as acutely unwell, not with psychological symptoms.
According to the ICD-10, which of the following is a core feature of depression?
A) Anergia B) Diurnal variation of mood C) Loss of appetite D) Suicidal ideation E) Waking early
A
The core symptoms are anergia, anhedonia, and low mood. At least one feature must be present for at least 2 weeks.
Biological features include change of appetite and weight, change in sleep pattern, loss of libido, and diurnal variation of mood (worsening in the morning).
Psychological features include feelings of guilt and hopelessness, poor concentration, low self-esteem, and suicidal ideation.
Which of the following antidepressants is not a serotonin specific reuptake inhibitor (SSRI)?
A) Citalopram B) Fluoxetine C) Mirtazapine D) Paroxetine E) Sertraline
C
Mirtazapine is a noradrenergic and specific serotinergic antidepressant with a tetracyclic structure. It is often used second-line, and does not usually cause nausea or weight loss. It can induce sleep.
